Cross-trigonal Reimplantation Research Articles

Long term outcomes of Cohen’s cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney

Long term outcomes of Cohen’s cross trigonal reimplantation for primary vesicoureteral reflux in poorly functioning kidney

Ureteral reimplantation aligned laparoscopically: Pneumovesicoscopic Politano-Leadbetter reimplantation in children

Ureteroneocsytostomy is a well-established procedure for correction of certain ureterovesical conditions like vesicoureteral reflux and ureterevesical obstruction. Amazing developments in technology paved the way for minimally invasive surgery and conventional procedures are increasingly being performed minimal invasively during the recent decades. Although Politano-Leadbetter ureteroneocystostomy is an anatomical repair, lost its popularity against Cohen's technique as it is more challenging to perform and requires extravesical dissection which may increase the complication rates. In this study, we evaluated our results and feasibility of laparoscopic intravesical (pneumovesicoscopic) repair of certain ureterovesical conditions by Politano-Leadbetter principle in children. Twenty one children who underwent pneumovesicoscopic uretero-neocystostomy are enrolled in the study. Surgical procedure is described and surgical duration, complications, conversion rate and success rates are evaluated. Fourteen (67%) of the patients were girls and 7 were boys (33%). Median age at operation was 6 years (1.5-15 years). Main indications for surgery were vesicoureteral reflux, megaureter and bladder diverticulum. Fourteen of the patients underwent bilateral (67%) intervention while the 5 left (24%) and 2 right (9%). Four patients were converted to open surgery (16%; 4/25). Median surgical duration was 265min (190-320min) for bilateral and 180min (115-260min) for unilateral procedures. Success rates confirmed by a contrast study were 92% for VUR. It appears that minimally invasive intravesical surgery fails to keep up with the other minimally invasive procedures secondary to restricted working field in the bladder, technically demanding procedures and well-documented high succes rates of open counterpart techniques. Although developing relatively slower, minimally invasive technology offers better vision, better cosmesis, lesser pain and lesser tissue disturbance. Although cross-trigonal reimplantation is the most popular technique, Politano-Leadbetter technique provides an anatomical alignment of ureters and is a good option for caudally located ectopic ureters. In our study, pneumovesicoscopic approach provided anatomical reimplantation, identification and sparing of vas deferens and better cosmesis. Major limitations of our study are the limited number of cases, longer operation times, higher complication rates and short follow up duration which we hope to improve with increasing experience. Although not brilliant as its open counterpart yet, initial results of pneumovesicoscopic reimplantation with Politano-Leadbetter technique is promising and growing experience would further improve the results and lower the complication and conversion rates.

Bilateraler Reflux – pro intravesikale Techniken

All surgical techniques in antireflux surgery are characterised by a high success rate of over 90 %. The common goal of all procedures is the formation of a submucosal tunnel which is four times longer than the diameter of the ureter. Successful treatment has been achieved worldwide with the extravesical antireflux technique according to Lich-Gregoir in non-dilated ureters and psoas hitch ureterocystoneostomy in dilated ureters. Intravesical surgical procedures include the Politano-Leadbetter technique and Cohen's cross-trigonal reimplantation. These open or laparoscopic/robotic standard procedures have higher rates of success than endoscopic subureteric injection.

Vesicoscopic cross-trigonal ureteral reimplantation: High success rate for elimination of primary reflux

Open ureteral reimplantation (UR) is the gold standard for the surgical management of vesicoureteral reflux (VUR). There have been increasing reports on robot-assisted UR, but this approach remains controversial due to reports suggesting increased complications and reduced success compared with open repair. This study presented extensive experience with vesicoscopic ureteral reimplantation (VR) for primary reflux. In this procedure, cross-trigonal reimplantation was performed in a manner analogous to open repair under carbon dioxide 'pneumovesicum'. To review outcomes of vesicoscopic cross-trigonal ureteral reimplantation and compare them with other minimally invasive approaches for the correction of reflux. All patients who underwent VR at the current institution were retrospectively reviewed. The following were recorded for each patient: age, sex, grade of reflux, operative time, outcome, and complications. The series consisted of 182 consecutive patients who underwent VR. There were 165 girls and 17 boys. Mean age was 7.03 years (range 16 months-38.2 years). Fifteen had failed prior injection therapy. Of the 182 patients, 135 underwent bilateral repairs and 47 unilateral. Mean operative time for bilateral repairs was 197 (112-284) minutes and 169 (99-288) for unilateral. Major complications included two ureteral obstructions: one resolved with stent placement and the other underwent re-operative reimplantation. Postoperative voiding cystourethrogram (VCUG) was obtained in 100 patients and was normal in 93 (93%). Four of these failures occurred in the first 30 patients. Of the last 49 patients tested, 48 were normal, suggesting a 98% effective success rate after the learning curve. Vesicoscopic ureteral reimplantation is an approach that completely recreates all aspects of open cross-trigonal repair. Complications were uncommon and success rates were very high in the current study. Vesicoscopic ureteral reimplantation is a minimally invasive procedure for the definitive repair of primary reflux. After the learning curve at the current institution, success rates were found to be equivalent to open repair and were higher than published reports of robot-assisted procedures.

VESICOURETERAL REFLUX

Objectives: The objective of our study is to compare the extravesical andintravesical ureteric reimplantation for the treatment of bilateral vesicoureteral reflux in children.Period: April 2013 and July 2016. Setting: Urology Department of Mayo Hospital, Lahore.Methodology: 66 children diagnosed with primary vesicoureteral reflux and undergoingureteric reimplantation. The Cohen cross-trigonal reimplantation (intravesical) and modifiedLich-Gregoir procedure (extravesical) were performed on two separate groups Group IRand group ER. The following parameters were compared: postoperative duration of stay inthe hospital, hematuria and bladder spasm. Frequency of hematuria, bladder spasm andaverage duration of stay in the hospital were compared in both group. Mean and standarddeviation was calculated for age, gender and duration of surgery in both groups.). Chi squaretest was applied to check the association of outcome variables with demographical variablesand duration of surgery. Results: These 100% (n=66) patients were divided into 2 groupsequally, 33 in each, i.e. group ER and group IR. The mean age and duration of surgery ofthe patients of group ER were 13.78±2.83 years, 102.45±4.13 minutes respectively. Whilethe mean age and duration of surgery of the patients of group IR was 30.33±4.58 years and119.7±10.70 minutes respectively (Table-II).The main outcome variables of this study werethe hospital stay, postoperative bladder spasm and hematuria. The mean hospital stay of thepatients of group ER and group IR was 4.30±1.35 days and 5.84±1.0 respectively (Table-II).It was observed that bladder spasm in group ER and group IR was 39.4% (n=13) and 54.5%(n=18) respectively (Figure-1). It was also observed that hematuria in group ER and group IRwas 36.4% (n=12) and 48.5% (n=16) respectively (Figure-2). Conclusion: The observation ofthis study concludes that extravesical ureteric reimplantation has an edge over conventionalprocedure of intravesical ureteric approach. Intravesical procedure has disadvantages of morefrequency of postoperative complications like, hospital stay, bladder spasms and hematuria.

EXTRAVESICAL VERSUS INTRAVESICAL URETERIC REIMPLANTATION IN CHILDREN

Objectives: The objective of our study is to compare the extravesical andintravesical ureteric reimplantation for the treatment of bilateral vesicoureteral reflux in children.Period: April 2013 and July 2016. Setting: Urology Department of Mayo Hospital, Lahore.Methodology: 66 children diagnosed with primary vesicoureteral reflux and undergoingureteric reimplantation. The Cohen cross-trigonal reimplantation (intravesical) and modifiedLich-Gregoir procedure (extravesical) were performed on two separate groups Group IRand group ER. The following parameters were compared: postoperative duration of stay inthe hospital, hematuria and bladder spasm. Frequency of hematuria, bladder spasm andaverage duration of stay in the hospital were compared in both group. Mean and standarddeviation was calculated for age, gender and duration of surgery in both groups.). Chi squaretest was applied to check the association of outcome variables with demographical variablesand duration of surgery. Results: These 100% (n=66) patients were divided into 2 groupsequally, 33 in each, i.e. group ER and group IR. The mean age and duration of surgery ofthe patients of group ER were 13.78±2.83 years, 102.45±4.13 minutes respectively. Whilethe mean age and duration of surgery of the patients of group IR was 30.33±4.58 years and119.7±10.70 minutes respectively (Table-II).The main outcome variables of this study werethe hospital stay, postoperative bladder spasm and hematuria. The mean hospital stay of thepatients of group ER and group IR was 4.30±1.35 days and 5.84±1.0 respectively (Table-II).It was observed that bladder spasm in group ER and group IR was 39.4% (n=13) and 54.5%(n=18) respectively (Figure-1). It was also observed that hematuria in group ER and group IRwas 36.4% (n=12) and 48.5% (n=16) respectively (Figure-2). Conclusion: The observation ofthis study concludes that extravesical ureteric reimplantation has an edge over conventionalprocedure of intravesical ureteric approach. Intravesical procedure has disadvantages of morefrequency of postoperative complications like, hospital stay, bladder spasms and hematuria.

A New Technique for Retrograde Flexible Ureteroscopy after Cohen Cross-Trigonal Ureteral Reimplantation

Purpose: Retrograde ureteral access after cross-trigonal ureteral reimplantation can be challenging. We present our experience with retrograde ureteral catheterization and flexible ureteroscopy after Cohen cross-trigonal reimplantation in patients presenting with ureteral stones. Materials and Methods: Cystoscopy is performed and a Tiemann ureteral catheter is inserted into the involved ureteral orifice. A retrograde ureterography is performed and hydrophilic guide wire is passed up to the kidney. A dual-lumen ureteral access sheath is then passed under x-ray control underneath the ureteral stone. The flexible ureterorenoscope is passed under x-ray control up to the stone which is then fragmented with a holmium laser. Results: From June 2006 to June 2010, this technique was successful in 8 patients without acute or delayed sequelae. Conclusions: Where the endourological expertise is readily available, the ureter can be accessed retrogradely even after Cohen cross-trigonal ureteral reimplantation in a safe, straightforward and effective modality.

Pneumovesicoscopic Correction of Primary Vesicoureteral Reflux (VUR) in Children. Our Experience

We report our experience with pneumovesicoscopic cross-trigonal ureteral reimplantation to correct primary vesicoureteral reflux (VUR) in children. 14 children (10 girls, 4 boys, aged 4 to 12 years) with persistent VUR ≥ grade III (5 bilateral, 19 refluxing ureters) underwent pneumovesicoscopic Cohen's cross-trigonal reimplantation. Under cystoscopic control, a first midline 5-mm trocar was introduced for a 0°\30° telescope at the dome of the bladder, and 2 left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The ureter was freed by creating a sharp plane between the detrusor muscle and the ureteral wall. If necessary, the ureter was tailored outside the bladder. Submucosal tunnel(s) were prepared with the help of scissors and graspers. The detrusor at the site of the ureter mobilization was repaired and ureteroneocystomy was performed using 4-5 interrupted absorbable sutures. A 12-Ch Foley catheter was introduced at the site of the dome port. The urethral and suprapubic catheters were removed 2-3 days after the procedure and the patients were discharged on day 3. One boy developed mild suprapubic emphysema postoperatively. Mean operating time was 136 min (range 80-230 min). No patient required conversion to the open technique. Renal US, VCUG, and MAG3 radionuclide scans were obtained in all patients between 3-6 months postoperatively, and provided evidence of reflux resolution in 13 out of 14 patients. Our experience seems to confirm that pneumovesicoscopic cross-trigonal ureteral reimplantation can be performed safely and effectively.

The effect of CO 2 pneumovesicum on upper urinary tract

Objective Pneumovesicum allows minimal invasive intravesical surgeries. The possible deleterious effect of intravesical CO 2 pressure is not known. We assessed the effect of CO 2 pneumovesicum on the urinary tract and renal function. Methods Pneumovesicum was established and maintained with CO 2 at 10 mm Hg in 10 sows. Cohen cross-trigonal reimplantation was carried out on the left ureter by a vesicoscopic approach. The right ureter was cannulated and served as control. CO 2 pneumovesicum was maintained for 2 hours. Color Doppler measurements of the upper urinary tract and blood sampling were carried out 30 minutes before and 2 hours after establishing pneumovesicum, and 30 minutes after releasing the pneumovesicum. Results Compared with the preoperative values, the bilateral anteroposterior diameters of the renal pelves increased significantly after 2 hours of the pneumovesicum ( P < .05). Thirty minutes after release of the pneumovesicum, the anteroposterior diameters decreased and showed no statistically significant difference compared with the preoperative values. No air embolus was detected in the ureters, renal pelves, renal veins, or renal arteries on either side 2 hours after establishing the pneumovesicum. There was no statistically significant change in arterial or venous blood flow. There was no significant change in the urea and creatinine levels 2 hours after establishing the pneumovesicum. Conclusion CO 2 pneumovesicum at a pressure of 10 mm Hg for 2 hours did not result in any demonstrable deleterious effect.

Single-Stage Perineal Urethroplasty for Continence in Female Epispadias: A Preliminary Report

To evaluate the results of single-stage new technique of perineal urethroplasty with double breasting of the urethra and bladder neck and sphincteroplasty in female patients with epispadias. We have treated 4 patients with severe female epispadias (male/female ratio 6:1) since 1991. They presented at the age of 3, 11, 12, and 23 years. Perineal urethroplasty with double breasting, sphincteroplasty, and genitoplasty was done in 3 cases. Cohen's cross-trigonal reimplantation with bladder neck reconstruction was done in the fourth patient who had an ectopic ureter, but the patient required perineal urethroplasty and genitoplasty because of partial incontinence. The urethral plate and bladder neck was mobilized from the surrounding tissue to the bladder neck. A urethral mucosal strip of about 5 to 10 mm was denuded from the bladder neck to the end of urethral plate on one lateral edge, and the urethral plate and urethral mucosa was tubularized over a 12F catheter. Urethroplasty was done with double breasting of the urethral muscle margins starting from inside the bladder neck downward to the neomeatus with corporoplasty, sphincteroplasty, and genital reconstruction. Of the 4 patients, 3 were fully continent during the day with a dry interval of 4 to 5 hours. One of the 3 patients was partially continent and had nocturnal enuresis, which responded to anticholinergic. The fourth patient with bladder neck reconstruction was partially incontinent initially but became continent after perineal urethroplasty. Our technique of one-stage perineal urethroplasty increases the urethral and bladder neck resistance, as well as the bladder capacity, all factors important for continence. This is a simple and effective method for the development of both continence and cosmesis in female epispadias repair.

Laparoscopic Transureteroureterostomy: A Novel Approach

We describe the feasibility and short-term results of laparoscopic transureteroureterostomy in children. We performed transperitoneal laparoscopic transureteroureterostomy with a 4-trocar technique in 3 children with a mean age of 63 months (range 18 to 105). Diagnoses were unilateral ureteral obstruction after cross-trigonal reimplantation for vesicoureteral reflux (1 patient), unilateral refluxing megaureter (1) and ureteral injury after bladder diverticulectomy (1). Cystoscopy, retrograde pyelogram and stent placement in the recipient ureter were performed at the beginning of each case. The anastomoses were carried out with running 6-zero reabsorbable sutures at the level of the pelvic bream. An abdominal drain and Foley catheter were left indwelling for 1 to 3 days. All cases were performed successfully. Postoperative course was uneventful except for a transient urinary leak, and patients were discharged home on postoperative day 2 to 4. At a mean followup of 6 months all patients were clinically well, with normal kidney function and blood pressure, and no significant hydronephrosis. Based on our initial experience, laparoscopic transureteroureterostomy is safe and effective, and is associated with little blood loss, minimal analgesia requirements, fast recovery and excellent cosmetic results. We believe that in selected cases in which transureteroureterostomy is the chosen technique a laparoscopic approach is advantageous.

Minimally invasive treatment for vesicoureteral reflux in children: a selective approach with effective cure for all

Purpose We report a minimally invasive treatment protocol for vesicoureteral reflux (VUR) in infants and children with a selective use of dextranomer/hyaluronic acid copolymer (Deflux) injection for mild grades or uncomplicated VUR and pneumovesicoscopic ureteric reimplantation for severe grades or complicated VUR. Material and methods Children presenting with persistent primary VUR (Grade II - V) refusing antireflux surgery were recruited. At entry, each patient had a voiding cystourethrogram (VCUG), renal ultrasonogram (US), isotopic renogram (DMSA).The minimally invasive management protocol included 1) endoscopic sub-ureteric injection for milder grades (Grade II -III, Grade IV unilateral) and 2) endoscopic Cohen's cross-trigonal ureteral reimplantation with CO2 pneumovesicum for dilating (Grade IV Bilateral to Grade V) VUR, associated with UTI and multiple pyelonephritic renal scarring. Resolution of VUR was confirmed by VCUG at a minimum follow up period of 6 months after the procedure. Results One hundred and seventeen patients (45 bilateral) were treated. Endoscopic sub-ureteric injection was given to 24 children (M/F: 8/16, Mean age: 5.75 ± 3.61yrs,72 refluxing ureters) and Endoscopic cross-trigonal ureteric reimplantation was successfully performed in 93 children (M/F: 72/21, Mean age: 5.1 ± 5.61, 90 refluxing ureters). Follow-up cystogram showed complete resolution of VUR in 69 ureters (96%), and in 89 ureters (99%), in those who underwent subureteric injection and ureteric reimplantion respectively. VUR downgraded in 1 (underwent surgical intervention) and persisted in 3 ureters treated with subureteric injection and were treated successfully by repeat injection. Conclusions This new minimally invasive treatment algorithm with a combined and selective use of Deflux injection for mild grades of VUR and endoscopic pneumovesical ureteral reimplant for severe VUR offers a very effective cure for all grades of VUR. The very high cure rate alleviates the need for follow-up VCUG's and long term antibiotic treatment.

Endoscopic Injection of Dextranomer/Hyaluronic Acid Copolymer to Correct Vesicoureteral Reflux Following Failed Ureteroneocystostomy

The efficacy of endoscopic injection of dextranomer/hyaluronic acid to correct primary vesicoureteral reflux is well documented. We present experience at 2 institutions with endoscopic treatment for vesicoureteral reflux after failed ureteroneocystostomy. A retrospective review was performed of the records of all patients who underwent endoscopic dextranomer/hyaluronic acid injection to correct vesicoureteral reflux following ureteral reimplantation between April 2002 and July 2005. De novo ipsilateral vesicoureteral reflux was noted after repair of primary nonrefluxing megaureters or renal transplantation and persistent vesicoureteral reflux was noted following attempted vesicoureteral reflux repair. Injection was performed using the standard technique if the ureteral orifice was easily accessible, and percutaneously if access was difficult. Nine male and 9 female patients were identified. Median age was 1.9 years at reimplantation and 6.5 years at injection, and median followup was 19 months. Ten patients underwent extravesical detrusorrhaphy and 8 underwent cross-trigonal reimplantation. Six patients underwent reimplantation for primary megaureter repair and all had resolution of vesicoureteral reflux with injection. Of the 20 renal units 16 (80%) and 15 of 18 patients (83%) had complete resolution of vesicoureteral reflux after 1 injection. One patient had improvement in vesicoureteral reflux and 2 had no improvement. There were no complications resulting from injections. Endoscopic treatment of vesicoureteral reflux with dextranomer/hyaluronic acid following extravesical or cross-trigonal reimplantation is safe and efficacious, at least at short-term followup. Endoscopic injection should be considered first line treatment for this situation.

Langzeiterfahrungen mit der Ureterozystoneostomie nach Cohen beim bilateralen vesikoureterorenalen Reflux im Kindesalter

In bilateral VUR, Cohen cross-trigonal ureteric reimplantation is a popular but also controversial surgical approach. We present our own experience in a retrospective analysis. Between 1990 and 2005, 41 children (26 girls, 15 boys) with bilateral reflux [92 renal units (RU)] underwent ureteric reimplantation. The mean age was 4.5 (0.3-12) years. Eight patients had ureteral duplication (six unilateral, two bilateral); 12 of 41 patients had no intraoperative ureteral stenting. Seven patients had prior surgery for VUR. A successful result was defined as absence of VUR, significant UVJ obstruction, or voiding dysfunction throughout the follow-up. The mean follow-up was 7.8 (0.5-15) years. Eight patients (19.5%) had 13 complications. One patient had an intraoperative small bowel lesion (2%). Six patients (14.6%) had UTI. Four patients (9.8%) showed transient UVJ obstruction. Three required a temporary percutaneous nephrostomy. Two of these patients had no intraoperative ureteral stenting. Recurrence of VUR was found in 2 patients (4.8%) and 2/92 RU (2.2%), respectively. Complications were more frequent in high-grade VUR, ureter duplex, or unstented ureteral reimplantation. Prior surgery for VUR did not influence the postoperative outcome. Postoperative voiding disorders were not observed. Two unilateral recurrences of VUR were observed, requiring a reoperation in one patient. A reoperation for UVJ obstruction was not necessary. Related to 92 RU the surgical success rate was 97.8%. Intraoperative ureteral stenting has to be considered with respect to the current discussion of shortening inpatient procedures. In our experience, the perioperative risk was elevated in patients with high-grade VUR or ureteral duplication.

A Novel Technique for Ureteral Catheterization and/or Retrograde Ureteroscopy after Cross-Trigonal Ureteral Reimplantation

A criticism of the Cohen cross-trigonal reimplantation is the potential difficulty of retrograde access to the ureter. With the advent of modern endourological equipment, we devised a novel technique that obviates the aforementioned difficulty and permits even retrograde ureteroscopy. Cystoscopy is performed and a curved tip vascular access catheter is directed towards the ureteral orifice. An angle tipped glide wire with a torque device attached is passed through the catheter and directed into the orifice. The combination of the curved catheter and angled glide wire permits passage of the wire in an axis perpendicular to that of the cystoscope. Once the glide wire has been passed into the proximal ureter it is exchanged for a super stiff guide wire. The latter literally straightens the ureter permitting direct retrograde passage of a catheter, stent or rigid ureteroscope. This technique was successful in 6 children. Of the patients 4 underwent retrograde ureteroscopy with stone extraction, 1 underwent retrograde studies followed by stent insertion and 1 underwent retrograde catheterization alone for radiographic studies. It is distinctly uncommon to have to access a ureter in a retrograde fashion after cross-trigonal reimplantation. However, when required the technique described reliably permits retrograde access and should dispel fears of long-term consequences of the Cohen ureteral reimplantation.

Intravesical Morphine Analgesia Is Not Effective After Bladder Surgery in Children: Results of A Randomized Double-Blind Study

Intravesical morphine was recently recommended to reduce postoperative pain after reimplantation surgery for vesicoureteral reflux in children. The efficacy of such treatment, so far solely evaluated by open study, needed to be confirmed. After parental informed consent was obtained, 80 children requiring Cohen cross-trigonal reimplantation were considered for inclusion in a double-blind study. On the day of surgery patients were randomly assigned to receive either 0.04 mg./kg. morphine per hour or placebo (normal saline) at a constant intravesical infusion rate of 0.08 ml./kg. per hour. Postoperative pain was assessed every 3 hours using a pain score adapted to patient age. If the score was above a predefined limit, patients received intravenous acetaminophen and nalbuphine alternately every 3 hours. Bladder infusion was discontinued after 48 hours. Mean and maximum pain scores as well as the number of scores above the limit were not statistically different when comparing the morphine and placebo groups. There was no difference in the number of doses of analgesics administered. Urine output, voiding frequency and the number of painful voiding episodes were not significantly different between the 2 groups. Plasma morphine concentrations were 3.0 +/- 2.7 and 1.9 +/- 1.9 ng./ml. at 24 and 48 hours in the morphine group and undetectable in the placebo group. Intravesical administration of morphine is not effective for relieving postoperative pain during the first 48 hours after intravesical ureteral reimplantation. This study emphasizes the importance of controlled studies in evaluating the effectiveness of a new drug or procedure before recommending its use for all patients.

VESICAL CONTINENCE IN BILATERAL ECTOPIC SINGLE URETERS

We explore the possibility of gaining suitable vesical capacity and continence in bilateral single ureters without having to resort to urinary diversion or bladder neck reconstruction. In the last 10 years we treated 6 girls with bilateral ectopic ureters, and 2 with a single kidney and urethral ectopic ureter. Both ureters were ectopic in the urethra in 3 cases, and 1 ureter was inserted in the urethra and 1 in the bladder neck in the other 3. Preoperative examinations included ultrasonography, cystography, excretory urography and endoscopy in all cases, and magnetic resonance imaging in 2. Patient age at intervention ranged from 1 month to 8 years. Cross-trigonal reimplantation of the ectopic ureters through a correctly positioned neomeatus was performed in 7 cases. In 2 patients it was impossible to reach the ureteral insertion from inside the bladder (1 ureter in 1 and both ureters in 1), and so the distal tract of these ureters was resected extravesically as close as possible to the urethra. One patient with a single kidney also had an anorectal malformation and a rectovaginal fistula. She had pelvic renal ectopia and the ureter was inserted beneath the urogenital diaphragm causing minimal bladder capacity. Therefore, a sigmoid neobladder with appendicostomy was constructed according to the Mitrofanoff principle. A Young-Dees bladder neck plasty was done in 2 patients at the same time as ureteral reimplantation and 3 years later in 1. Followup urodynamics revealed more than acceptable continence. Bladder capacity was insufficient in only 1 polyuric patient. A bladder with bilateral ureteral ectopia is not necessarily useless, and the majority of patients can achieve normal bladder function and capacity along with normal transurethral voiding and satisfactory continence.

Is primary obstructive megaureter repair at risk for contralateral reflux?

Contralateral vesicoureteral reflux occurs after successful unilateral reflux repair in a significant proportion of patients without correlation to the surgical approach. Unilateral congenital obstructive megaureter was compared to primary vesicoureteral reflux with regard to the risk of onset of contralateral reflux after unilateral ureteral reimplantation. Unilateral congenital obstructive megaureter was diagnosed in 58 consecutive patients 2 to 10 years old (mean age 3.2). Cross-trigonal ureteroneocystostomy was performed in 57 cases and longitudinal ureteral reimplantation, according to the Politano-Leadbetter technique was done in 1. Longitudinal tapering according to Hendren was performed in 44 ureters, and the Kalicinski folding was used to repair 11 ureters. All patients underwent serial renal ultrasound, diethylenetetraminepentaacetic acid nuclear scan, excretory urogram and voiding cystourethrogram. The control group was composed of 98 age matched children with unilateral vesicoureteral reflux who underwent unilateral reimplantation with or without tapering. Fisher's exact test and Student's t test were used for statistical analysis. Followup ranged from 1 to 5 years. All patients in both groups underwent a voiding cystourethrogram at 6 months, and renal ultrasound at 3, 6 and 12 months postoperatively. Grade 2 reflux developed in 1 study group patient after contralateral Kalicinski ureteral folding and cross-trigonal reimplantation (1.7%). In the control group new onset contralateral reflux developed in 11 cases (11.2%). The difference was statistically significant (p <0.005, Fisher's exact test p = 0. 033). Ureteral reimplantation for unilateral congenital obstructive megaureter is not correlated with the development of contralateral reflux. The occurrence of contralateral reflux after successful unilateral reflux repair is high (11.2%), and is not correlated with age, sex and technique of reimplantation or tapering. These results support the hypothesis that the functional anatomy of the trigone is preserved in congenital obstructive megaureter but is impaired on both sides in cases of unilateral vesicoureteral reflux. The surgical management of unilateral primary vesicoureteral reflux and congenital obstructive megaureter should be differentiated based on these results.

Percutaneous transvesical ureteroscopy for removal of distal ureteral stone in reimplanted ureter

In the past two decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation, with the potential for diagnostic and/or therapeutic ureteroscopy. The anatomic orientation of the ureters resulting from a cross-trigonal reimplantation may create difficulty or even inability to perform transurethral ureteroscopy. This case presents the technique of percutaneous transvesical ureteroscopy for stone extraction in a seventeen-year-old male with a lower ureteral stone following cross-trigonal ureteral reimplantation. The described technique may serve as an addition to the current endoscopic methods.

Vascular Integrity of the Distal Ureter following Combined Tapering and Cross Trigonal Reimplantation

Massive unilateral hydroureteronephrosis was created in 20 female dogs by ligating the urographically normal prevesical ureter. Over a 14-day period the obstructed ureter dilated to an average of 15.3mm. A ureteral tapering procedure was performed by lateral darting and posterior folding of the resultant flap, followed by a cross-trigonal reimplantation. One anastomotic stricture resulted; in the remaining 19 animals, ureteral peristalsis was restored, the ureteral diameter was reduced 61.9 per cent and hydronephrosis was resolved. Histological studies on the tapered segments of these 19 animals showed that the subadventitial blood supply was preserved with fibrotic occlusion of the folded flaps.These results demonstrate that no significant vascular compromise after ureteral tapering and cross-trigonal reimplantation occurs. Success rates comparable to those of conventional ureteral tailoring can be achieved by this technically simplified form of reconstructive surgery.